President-elect Donald Trump is seen Thursday with House Speaker Paul Ryan of Wisconsin on Capitol Hill in Washington. They plan to repeal and replace the Affordable Care Act. Alex BrandonThe Associated Press

President-elect Donald Trump is seen Thursday with House Speaker Paul Ryan of Wisconsin on Capitol Hill in Washington. They plan to repeal and replace the Affordable Care Act. Alex BrandonThe Associated Press

If Trump repeals Obamacare, will Washington state foot the bill?

State lawmakers from both sides of the aisle agree: Donald Trump’s promise to dismantle President Barack Obama’s signature health care law could bring a huge headache for Washington state.

The repeal of the Affordable Care Act, more commonly known as Obamacare, would cause a flood of low-income people to lose health coverage if it isn’t replaced with something comparable.

That could leave the state facing a hefty tab if state legislators decide to replace the federal money that paid for the expansion of Medicaid. The fix could cost the state billions of dollars, said GOP state Rep. J.T. Wilcox of Yelm.

“It’s going be to like McCleary,” Wilcox said, referring to the state Supreme Court’s 2012 ruling that the state must fix the way it pays for education by 2018, “one of those great big bogeys out there that we’re all going to have to deal with.”

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Washington went all in on Obamacare, which was signed by the president in 2010.

It was one of 14 states to create its own online insurance exchange, where people without employer-provided health care can shop for a plan. State lawmakers also chose to take huge amounts of money from the federal government by opting for Obamacare’s expansion of the Medicaid government health care program that covers low-income people.

About 600,000 Washingtonians have gained coverage because of the Medicaid expansion, according to the state Health Care Authority, more than double the amount originally predicted in 2013.

The cost of that expansion now is paid for entirely by the federal government, according to the authority. The state is due to pick up some of the bill beginning next year. By 2020, the state is expected to cover 10 percent of the cost.

State officials couldn’t say how much money is at stake if Obamacare is repealed. On Monday, the health authority was still analyzing exactly how much money the federal government pays to cover those 600,000 people who joined Medicaid.

Whatever the number, it’s expected to be big. Bob Crittenden, Gov. Jay Inslee’s health care reform adviser, said finding enough money to cover new Medicaid enrollees would be especially tough right now, considering lawmakers are grappling with the remaining cost of meeting a court order to fully fund education and its estimated $3.5 billion price tag.

Without the Medicaid expansion or a replacement: “Our people would be a lot sicker,” Crittenden said.

Some of the people who lose health care coverage would end up in the clinics of last resort: hospital emergency rooms. Loss of federal money for Medicaid expansion could drive up “charity care” costs of uninsured hospital visits that hospitals, and in turn their paying patients, have to cover.

After Obamacare was implemented, charity care costs dropped for the first time since the state began collecting data on it in 1989. Charity care spending went from $1.4 billion in 2013 to $942 million in 2014, according figures provided by the state Department of Health.

Rising charity care costs could put “a huge strain” on some hospitals, said Mary Kay Clunies-Ross, a spokeswoman for the Washington State Hospital Association.

State Rep. Eileen Cody, D-Seattle, said she is worried, but finds it “really hard to imagine” Republican members of Washington’s congressional delegation would “vote to kick thousands of people in their districts off health care.”

In other words, there may not be enough support in Congress, even among Republicans, to fully repeal Obamacare. Or at least not all at once, said Cody, who chairs the state’s House Health Care Committee.

Crittenden noted Kentucky, the home state of Senate Majority Leader Mitch McConnell, and Indiana, where Vice President-elect Mike Pence is governor, both chose to take federal money to expand Medicaid.

Cody said the repeal of Obamacare might be done incrementally rather than dropping huge problems on the Legislature in the immediate future.

“Am I nervous? Yes. Am I panicked? No, not yet,” she said.

Some predict that change could come faster.

“I fully expect some kind of Obamacare repeal or replacement enacted in January or February,” said state Rep. Drew Stokesbary, a Republican from Auburn who was not a Trump supporter.

What a replacement of Medicaid might look like is hard to determine. The federal government, in addition to providing money for those who joined Medicaid after Obamacare expanded eligibility, also matches state funds for the enrollees who qualify under the old rules. Speaker of the U.S. House Paul Ryan, R-Wisconsin, has advocated replacing that funding with a lump sum, known as a “block grant,” that states could use at their discretion.

Because no official Republican proposal exists yet, it’s tough to speculate if those block grants would be enough to allow health coverage equivalent to that under Obamacare, according to Clunies-Ross.

State Sen. Doug Ericksen, Trump’s deputy campaign director in Washington, said the state shouldn’t have taken the Medicaid expansion in the first place because there was never a guarantee the federal money would always be there.

Ericksen, R-Ferndale, said it is “difficult to say” if Medicaid expansion will survive under the next administration. On Friday, Trump told the Wall Street Journal he is willing to keep some aspects of Obamacare, including protections for people with preexisting conditions and years of additional coverage for children on their parents’ insurance policies.

Technically, some parts of Obamacare could survive the federal law’s reversal.

Washington’s health care exchange, for example, is paid for by the state and could stand on its own, said Michael Marchand, spokesman for Washington’s Health Benefit Exchange. The state budgets about $50 million a year for the operations and technology costs of the exchange.

But without the federal subsidies that some users of the exchange get to buy health insurance, fewer people could afford to use the exchange.

Ericksen said Trump will “fundamentally restructure” the health care system in ways that will help people get affordable insurance. He cited two of Trump’s main proposals to lower the cost of insurance — allowing people to buy health insurance across state lines and making health savings accounts more available.

Wilcox said a Medicaid fix, if one is needed, will have to come from Democrats.

“I don’t know what the answer is at this point,” he said. “I’m looking for some leadership from the House Democrats who were the ones who embraced this so enthusiastically.”